Re-Imagining How Iowa's Systems Work Together to Best Serve Families

In 2018, Congress passed the Family First Prevention Services Act, prioritizing funding for services that keep children safely with families instead of in foster care. As the Iowa Dept. of Human Services (DHS) considered what this shift would mean for the child welfare system it manages, the Coalition for Family and Children’s Services in Iowa convened a group of stakeholders within DHS and who interact with the system to discuss the transition. The conversation quickly moved beyond specifics of the Family First Act.

“The discussion became: How do we transform a system so we can best support kids and families,” said Kelli Soyer, Associate Director of the Coalition.

With grant funding from Mid-Iowa Health Foundation, the Coalition formed The Vision Council to guide this big-picture conversation. After two years, 23 members are working in four committees to lead intentional steps designed to move state systems that interact with families toward the North Star outcome: Iowa’s families and children will be safe, secure, healthy, and well in their communities.

“I think most stakeholders agree with the philosophy of Family First, but making shifts in the way organizations operate is daunting,” said Denise Swartz, Senior Program Officer at Mid-Iowa Health Foundation. “I was really impressed with the way the Vision Council not only presented the concept of working all together to find the best way to serve kids and families, but then once they received a Foundation grant, how they went all in and are working to change the system and figure out a way for us to collectively operate in a better manner to serve kids and families.”

Using a Results-Based Accountability framework

The Family First Act was primarily a change in the funding structure for child welfare services. Under the previous model, the state received federal funding if a child was removed from their home. The Act flipped that to focus on funding evidence-based practices that support families and prevent kids from being removed from their families. The Act also limits the number of kids who can be placed in group-care settings.

With this change, “we realized there needed to be a shift in mindset of how people do their work,” said Kristie Oliver, Executive Director of The Coalition for Family and Children’s Services in Iowa. “It was an opportunity to think through that together as a system and to not feel like we were being told what to do.”

The Coalition was uniquely positioned to lead this conversation through its mission to elevate the collective impact of agencies across Iowa that serve children and families most at risk for entering the child welfare system. The Coalition initially convened 18 people within DHS or organizations who contract with DHS, as well as stakeholders in the Iowa Department of Public Health (IDHP) and Juvenile Court Services.

Bringing together DHS employees and providers who contract with DHS was especially important. Providers were concerned about what the Family First Act would mean for the services they provide, while DHS staff often feel as though they must carry the responsibility for the entire system.

“The Vision Council was focused on how we build a system for kids and families and not just respond to what a funding stream can do for us,” said Soyer. “There’s been a different level of engagement and some different voices—not just that it’s DHS’ responsibility. It takes so many people at the table to be successful.”

With MIHF grant funding, the Coalition hired Marlo Nash, a consultant, to lead the group through a Results-Based Accountability framework that starts with identifying the end difference you are trying to make and works backward to get there using a data-driven decision-making process.

At a meeting early in the process, Vison Council members reviewed data placed around a room and discussed what the data was telling them. The data review especially helped the group see what was happening across systems, which isn’t always seen, as different agencies and programs handle different services for families who are at risk.

“When we came back together, one of the first comments from a participant was, ‘Racism, anyone?’” said Soyer. “It was very clear to us that we needed to be looking through a race equity lens and through at trauma-informed lens as we were committing our work to this transformational change.”

The group also conducted a culture inventory to better understand the current culture of the child welfare system and what people wanted the culture to be. The inventory asked people at DHS, in the legal system, with lived experience, and others connected to the child welfare system to complete a 100-question survey. The first survey asked about the current culture of the system. A second survey completed one day later asked what culture they wanted to see.

The culture inventory laid the groundwork to focus on moving “to” something instead of moving “from” what currently exists. “We tend to put ourselves in a fixed mindset—what has to be fixed—versus a progress mindset that focuses on how we become innovative and a part of the solution,” Soyer said.

New ways of looking at the work

Through conversations about data and culture, the Vision Council began to define the long-term transformational change stakeholders wanted to see. The North Star Outcome – Iowa’s families and children will be safe, secure, healthy, and well in their communities – was further broken down into what the group meant by each of the terms. As the big picture was defined, they also looked at the process for getting there.

Nash shared a few ways of thinking about the work that supported a shift in thinking to keep people focused on the bigger vision. The “From-To” shift was one way. Another was the importance of communicating “why” as well as “what” to help people understand change taking place.

The Vision Council also had discussions about working across systems and geographical regions and how to build on families’ strengths instead of focusing on the problems they’re experiencing. Council members examined the historical mindset that separation means safety for kids to today’s understanding that kids do best in families.

Nash gave the group tools to help drive these mindset shifts. These frameworks and tools helped the Council focus on not duplicating work, but instead, how to help shift the overall culture of family-serving systems throughout all the work. Stakeholders applied these approaches when hosting meetings and noted that it helped provide greater purpose and clearer outcomes.

“It helps when you go to meetings and the focus is on results, not just reporting out but trying to work together for system change and identifying barriers and solutions and where we go from here,” said Dawn Kekstadt, Bureau Chief of Child Welfare and Family Services, who represented DHS on the Vision Council from 2019 to mid-2021.

“The Vision Council has offered space and time to learn how to think differently about how we work both within and outside of our system,” said Chris Koepplin, CEO of Ellipsis, a nonprofit organization focused on helping children, youth, and families receive care and support through challenges. “I’ve been able to use the skills and strategies I’ve learned in the Vision Council internally in my own organization, as well as with external groups and colleagues.”

Working toward the North Star

With the North Star outcome established, the Vision Council identified specific gaps in the system not being addressed and, in year two, broke into four work groups to further examine data, specify target audiences, and set goals that would lead to change.

The North Star work group has examined the economic and social factors that impact families and what indicators will show progress toward the larger vision. They looked at research that showed a connection between how adverse experiences, including inadequate housing and financial insecurity, drive involvement in the child welfare system and are reviewing successful strategies—like supportive housing that prevents homelessness—to reduce child removals.

The Substance Use Disorder work group brought together stakeholders addressing the issue across DHS, IDPH and the courts. As members analyzed data, they focused their attention on families with children ages birth to age 10 whose parents are struggling with substance use, putting their children at greater risk for being in the child welfare system. The group surveyed adult behavioral health providers to identify their use of evidence-based practices that support a family-centered, recovery-oriented approach to substance use treatment. A webinar series, supported by two managed care organizations, will engage providers on how Family First, substance use, mental health, and behavioral health are interconnected.

The Older Youth work group formed after the Council recognized a lack of focus on, and gaps in, evidence-based services and supports for older youth in the child welfare and juvenile justice systems. Data especially showed that youth of color were disproportionately involved in out-of-home placements. The work group is analyzing strategies and progress measures to improve conditions for young people of color, including identifying evidence-based practices that could be funded under Family First and focus on safely keeping young people connected to family and fictive kin.

Another group is connecting and engaging with other stakeholders and groups to avoid duplicating efforts as the Family First Act is implemented, as well as engaging partners to sustain the work of the Council. The work groups noted above, for example, are now led by stakeholders on the Vision Council. In addition, 11 participants were trained in Results-Based Accountability and are spreading this model through family-serving systems so that stakeholders are aligning efforts and resources using shared language and focusing on agreed upon results.

“I think these groups have been very thoughtful in identifying areas and building out real strategic recommendations,” said Kekstadt. “It helps give ownership not just for DHS for a shift in the system. It's everybody’s responsibility and the whole system has to shift. It’s really a systematic change in philosophy.”  

Seeing shifts occur

Shifting systems to move toward the North Star outcome takes time and starts with building a trusting culture. The Vision Council spent several months building that culture so members could be open about what they see in the system and the shifts they want to make.

“It moves a lot slower than we all want it to,” Oliver said, “but when you don’t know what you don’t know, and each part of the system doesn’t know what the other part of the system is doing, it takes time to understand each other to then move forward.”

This process has helped build understanding between different entities. On the Substance Use work group, IDPH and DHS have become better connected to understand how their work impacts each other, which is furthering the state’s goal of merging the two departments.

“It’s getting everyone that’s participating out of the ‘us versus them’ mindset and supporting them to take accountability for their own actions and thoughts,” said Oliver. “It’s understanding that we’re all in this together and that’s a true culture shift. We’re getting there.”

The group’s work also is inspiring shifts in thinking across systems. A presentation to the court system in November 2020 led to six of the eight judicial districts prioritizing efforts to look at substance use through a family-centered and recovery-oriented approach. A new group formed among DHS, Managed-Care Organizations, and providers is reviewing data to create financing solutions for evidence-based best practices that assist children and families. HealthConnect Fellow Andrea Dencklau’s study examining opportunities to support kinship caregivers more effectively, along with her work on the Older Youth work group, are inspiring changes within DHS, including offering kinship caregivers a larger stipend to cover the cost of caring for children and better guiding social workers on how to engage kinship caregivers.

Most recently, The Vision Council presented ideas to the state for how to use the American Rescue Plan dollars to elevate initiatives that uplift families impacted by the pandemic. This opportunity was a way for the Council to put forward its bigger vision. For example, it presented cross-system changes that could improve outcomes for families working to recover from substance use disorders.

“I’ve seen the group find their way toward thinking about families as end users of all services and not about our services as the focus of the work,” said Greg Bellville, Executive Director of Prevent Child Abuse Iowa who leads the substance use work group. “The conversation is continuously being centered around the family and how one integrated system can seamlessly connect families with support services, like substance use treatment and family support, rather than looking at those services individually within separate systems.”

Oliver said this willingness to think big picture and collaborate is especially encouraging at a time when providers are struggling with a severe workforce shortage and systems are overwhelmed with challenges. The work has become even more critical as the pandemic has elevated families’ needs for support, especially related to issues of housing insecurity and poverty, which can lead to child maltreatment.

Organizations involved in the Vision Council work, like Prevent Child Abuse Iowa, are seeing these kinds of shifts benefit their missions as well.  “We are working on advocating for a way to get families a single touchpoint for both DHS and IDPH and access to resources when they need it, and not as a reaction to some negative event,” Bellville said. “There is now a group of people thinking about how it all works together.”

“The work of the Vision Council has encouraged us to be brave as we approach our work together,” said Koepplin. “We’ve been able to break down silos and collaborate across systems in ways that I haven’t seen before. We’ve had direct and difficult conversations from a place of true partnership. I’ve been able to take that boldness into different interactions with a wide variety of people I work with and I’ve seen others do the same. Somehow things feel more transparent and honest than they ever have before, which is great, because our current environment needs us all working together if we are going to truly help kids and families succeed.”

Looking forward

With another grant from Mid-Iowa Health Foundation, the Coalition is focused on creating a sustainable infrastructure to support work groups as they put their plans into action to improve outcomes for their target populations and to align more partners to drive toward the North Star outcome.

“We were really spearhead thinkers for systems change,” Soyer said. “The model relies on engagement across the broader community of people and organizations who are doing the work and how we can all inform and support and aligned process.”

One ultimate sign of success would be to see this mindset shift carried out into day-to-day jobs so that it becomes automatic as people in family-serving systems make decisions. Instead of thinking just about their work, people see how the decisions they make are part of a greater system.

“When stakeholders really look at ways to connect with one another, it’s outstanding what they can accomplish,” said Swartz of Mid-Iowa Health Foundation. “It’s about a shared language, understanding, and culture. The way the Vision Council has decided to work together is rubbing off on systems they interact with and organizations they are interacting with, which is exponentially increasing the culture of collaboration.”